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Making history with excellence in comprehensive medical care

Annual Report 2015 Data

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Index Mission & Vision HIMA San Pablo Oncologic Hospital………………………………………………………………………………………………..4 Message from the Medical Director ……………………………………………………………………………………………………………………….…5 Message from Cancer Liaison Physicians ………………………………………………………………………………………………………………….6 Program Management Tumor Boards: Optimizing Comprehensive Medical Care………………………………………………………………………….…..9 Multidisciplinary Rounds …………………………………………………………………………………………………………………….………12 Systemic Therapy Training Program ………………………………………………………………………………………………….………..14 Clinical Research ………………………………………………………………………………………………………………………………………..16 Patient Outcomes Prevention and Screening Programs …………………………………………………………………………………………………………..22 Educational Support …………………………………………………………………………………………………………………………….…….28 Multidisciplinary Support …………………………………………………………………………………………………………………………..31 Psychological Support ………………………………………………………………………………………………………………………………..33 Nutritional Support …………………………………………………………………………………………………………………………………….35 Continuum of Care Survivorship Care Plan ……………………………………………………………………………………………………………………….……….38 Quality Improvement Waiting Time for Radiation Therapy ……………………………………………………………………………………………………...……42 Study of Quality End of Life Protocol ………………………………………………………………………………………………………………………….…………44 Data Quality Overview of the Cancer Registry………………………………………………………………………………………………………….………49

Rapid Quality Report System ……………………………………………………………………………………………………………….……..53 HIMA•San Pablo Oncologic Hospital Alliances American Cancer Society …………………………………………………………………………………………………………………….………55 HIMA•San Pablo Oncology Foundation ……………………………………………………………………………………………….……..56 Susan G. Komen …………………………………………………………………………………………………………………………………….……57 Cancer Committee and Medical Faculty ………………………………………………………………………………………………………….……..59 Nadie te Cuida como Nosotros ………………………………………………………………………………………………………………….…….……..66

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HIMA•SAN PABLO ONCOLOGIC HOSPITAL Pink for the Cure 2015

Caguas, Puerto Rico

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HIMA•San Pablo Oncologic Hospital Mission

To improve cancer patient survival and quality of life providing patient-centered comprehensive medical care with initiatives and programs for health education and promotion, prevention, early detection and the highest quality medical and psychosocial care.

Vision

To become the best oncology hospital in Puerto Rico with its outstanding medical faculty and state of the art technology executing high quality, evidence-based medical care.

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Message from the Medical Director:

I am delighted to present our 2015 HIMA•San Pablo Oncologic

Hospital Annual Report. This report communicates our activities,

program accomplishments, and our cancer statistics throughout the

year. We continue to strive to be the leader in our region providing

state of the art cancer care as the only private Comprehensive Cancer

Program accredited by the American College of Surgeon’s

Commission on Cancer (CoC) in Puerto Rico.

One of this year’s highlights is the incorporation of Dr. Carlos

González García to our radiology team. Dr. González García has a

breast imaging fellowship which contributes to enhance our

diagnostic and screening program as we rename our breast dedicated

facility as “HIMA•San Pablo Breast Institute”. Our breast

reconstruction program has also grown thanks to the leadership of

our plastic surgeon Dr. Diana Avilés Castillo.

Another accomplishment in 2015 was to rearrange our inpatient

ward so all oncology dedicated wards are in the same hospital floor.

This has improved patient satisfaction by having our oncologic

specialized support team of nutritionist, social workers, and

discharge planner personnel all working together with our pediatric,

adult and stem cell transplant wards. This setting has greatly helped

with cross training of our nursing personnel.

Surgery remains the mainstay in curing most type of cancer;

therefore, this year we have updated with a newer version of the Da

Vinci Robotic Surgery System, allowing our surgeons to perform

more delicate and complex oncology surgeries with increased

precision and improved patient recovery.

Our goal is to deliver and embark on new projects to bring the latest

technologies and treatments to our patients in Puerto Rico and

surrounding islands.

Edgardo J. Rodríguez Monge, MD Medical Director HIMA•San Pablo Oncologic Hospital

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Message from Cancer Liaison Physicians:

It is hard to believe that it has been two years since the Commission on Cancer of the American College of Surgeons cancer program

accreditation at HIMA•San Pablo Caguas. As we near completion of the three year cycle and prepare for our next site visit, it is important to

look back on the development of our program so that we can set our goals to further development in the future.

The program began as an idea to have HIMA•San Pablo become the first fully private hospital in Puerto Rico joining the ranks of major

institutions in the United States which provide care to the majority of cancer patients. The Cancer Committee was established to provide a

framework for development of the program. The Tumor Board meetings went from a once a month conference involving general surgery to 5

monthly specialty meetings which are: general surgery, gynecologic oncology and urology, breast surgical oncology, head and neck surgery,

neurosurgery and pediatric surgery. I am proud to say that all Tumor Boards are directed by the attending surgeons in our different

departments. Assistance and input from the pathology, medical oncology, and radiation oncology make discussion and planning of treatment

a pivotal part in the care of cancer patients at HIMA•San Pablo.

In addition, we have established a robust collaboration with our social work, nutrition and psychology practitioners as well as an outstanding

support from the Health Educator. In this regards, special needs of patients are identified and acted upon quickly thus ensuring the best

outcome for our patients.

An integral part of the cancer program is the Tumor Registry. It has grown from a small corner office, to a fully functional department with 3

Certified Tumor Registrars and supporting staff. Full collaboration between the registry and the physicians involved in the cases assures that

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the information gathered and processed is of the best quality. This has been confirmed by review of our data transmitted to the National

Cancer Data Base and to the Puerto Rico Health Department, in which we are in full compliance.

What is the next step in the evolution of the Cancer Program at HIMA•San Pablo? We cannot isolate ourselves nor ignore the economic and

social environment in Puerto Rico at the present time. We will be treating an ever aging population due to in part, to increased longevity, but

also due to the increasing migration of the productive workforce to the United States mainland in search of better work opportunities. Physician

migration and exodus of nursing staff will continue to be a challenge as access to high quality health care may become limited. Finally, changes

in the health care insurance, with Medicaid and Medicare Advantage being the main players in the field with the respective nuances and

problems and limitation of service to patients, at some point may become a critical issue.

Fortunately, practicing in an Accredited Commission on Cancer Hospital may palliate most of the problems patients will face. Maintenance of

a solid structure in the delivery of care in a setting which maintains the highest standards – will guarantee that our patients receive the same

quality of care that they would in world class facilities. A structured multidisciplinary approach which includes education, early detection, high

quality surgical care and adjuvant treatment, will result in our patients getting the best therapy and the best outcome.

Our hospital - HIMA•San Pablo Oncologic Hospital through the Accreditation of the CoC has made a solid investment in leading the hospitals

in Puerto Rico in achieving the most modern and up to date treatment for cancer patients. It is our hope that in this next phase in the life of

our cancer program, HIMA•San Pablo Oncologic Hospital will continue to open the paths for others to follow.

Ramón K. Sotomayor, MD, FACS Mayra M. Collazo Castro, MD, CTR Surgical Oncology Director HIMA•San Pablo Oncologic Hospital HIMA•San Pablo Oncologic Hospital

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PROGRAM MANAGEMENT

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TUM

OR

BO

AR

DS:

O

ptim

izin

g C

om

pre

hensiv

e M

edic

al C

are

CME

Breast Cancer Tumor Board

Priscilla González-González Tumor Board Coordinator

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Monitoring Cancer Conference Activity 2015

Oral Cavity / Pharynx 7

Digestive System Stomach 1 Colon Excluding Rectum

19

Gall bladder 3 Liver 4 Spleen 1 Pancreas 3

31

Peritoneum, Omentum & Mesenter 1

Lung 5

Breast 127

Brain & CNS 96

Gynecology Cervix Uteri 1 Ovary 5

6

Prostate 3

Testis 3

Urinary System Kidney & Renal Pelvis

7

Bladder 3

10

Thyroid 2

Lymphatic System 11

Blood / Bone Marrow 2

Soft Tissue 6

Connective Tissue 1

Bone 6

TOTAL 317

HIMA•San Pablo Oncologic Hospital offers Tumor Boards on a

weekly basis. Tumor Boards are multidisciplinary meetings in

which a number of doctors and allied health professionals in

different specialties review and discuss patient medical condition

and treatment options to assure high quality comprehensive

medical care. During 2015, 46 Tumor Boards were given according

to the National Treatment Guidelines and AJCC Staging. A total of

317 cases were presented, 97% of them prospectively.

Oncologists and medical staff attending to these meetings

included: a medical oncologist, surgeon, plastic & reconstructive

surgeon, radio-oncologist, radiologist (including sub-specialists in

breast imaging, pediatric radiology, neuro-radiology, and

interventional radiology), nuclear physician, pathologist,

nutritionist, speech therapist, oncology nurse, social worker,

health educator and psychologist.

Tumor Boards help with patient referral to other services such as

genetic counseling, patient navigation and clinical trial, among

others. Feedback from different experts increases patient

outcome and quality of life.

SITES DISCUSSED (317 CASES)

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SPECIALIZED TUMOR BOARDS are scheduled from 11:30 am to 1:30 pm as follow:

Breast Surgery – Bi monthly (first Thursday and second Monday of each month)

Surgery & Medical Oncology – second Monday of each month

Neurosurgery and Head & Neck Surgery – third Thursday of each month

Pediatric Oncology – last Thursday of each month

CONTINUING MEDICAL EDUCATION (CME)

Starting November 2011, Tumor Board attendance receives 2 hours credits of Continuing Medical Education by the

Accreditation Council for Continuing Medical Education (ACCME) and the PR Board of Medical Examiners through a

joint sponsorship between Universidad Central del Caribe School of Medicine (UCC) and HIMA•San Pablo Caguas.

During 2015, a total of 96 hours of Continuing Medical Education were offered free of charge to physicians. A total of

52 doctors benefited from the initiative. In 2015, multidisciplinary attendance achieved a 96%.

Neurosurgical Oncology Tumor Board

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Objectives …

To ensure high quality patient-centered, comprehensive medical care. To deliver in-house

training for oncology nursing staff.

Multidisciplinary Rounds Jannette Camacho Rosario, RN, BSN, MSN Oncology Nursing Manager

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HIMA•San Pablo Oncologic Hospital Multidisciplinary Rounds

Background

Multidisciplinary Rounds are performed weekly at the adult oncology ward to ensure high quality care. Meetings help

to review and discuss patient clinical performance and psychosocial needs in order to coordinate follow-up

interventions with a multidisciplinary, patient-centered approach. The oncology nursing staff is in charge of presenting

performance status of each patient individually, while the HIMA•San Pablo Oncologic Hospital Medical Director leads

the multidisciplinary discussion.

Procedures

Multidisciplinary Rounds take place every Tuesday morning in the adult oncology ward.

Meetings last for one-hour period.

Meetings attendance include: oncology nursing staff, dietitian, health educator, social worker, pharmacist,

patient navigator and additional physicians within others.

Patient assessment is documented in writing by the nursing staff.

Accomplishments

Better communication between health care team members.

Coordination of clinical and psychosocial services for patients and caretakers prevent misuse of resources.

Increased sense of empowerment and confidence for decision making among the nursing staff.

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Objectives …

To ensure that nursing staff is properly trained in evidence-based guidelines for safe delivery of systemic cancer therapy.

To provide understanding of cancer as a disease.

Clinical Interventions for the Comprehensive Cancer Patient Care is the

name of the on-going training program especially designed by the

nursing leadership at HIMA•San Pablo Oncologic Hospital for the

nursing staff. It is offered one to three times a year to ensure high

quality nursing care for both adult and pediatric cancer patients.

In 2015 the program was held on December 16, for 26 nurses working

in Oncology Units or qualified for cross-training in the administration of

systemic therapy. The program was provided by Medical Oncologists

and Certified Oncology Nurses.

Systemic Therapy Training Program Irma Cruz Delgado, RN, BSN, OCN Oncology Nursing Supervisor

Hea

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The training program includes the following topics:

Competence of the Oncology Nurse.

Policies and procedures required for safe administration of chemotherapy.

Preventing and managing systemic therapy side effects and toxicities.

Preventing and managing extravasations.

Planning and managing vascular access.

Pain control in cancer care.

Safety management of morphine for cancer pain relief.

Patient psychosocial care.

Patient rights at the end-of-life.

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During 2015, HIMA•San Pablo Oncologic Hospital actively participated in 15 research initiatives presented elsewhere.

Among the most relevant to mention in this Annual Report are:

a) the MOFFIT Cancer Center/Ponce School of Medicine/HIMA•San Pablo agreement for the foundation of the

Puerto Rico BioBank,

b) the Medical Sciences Campus/ HIMA•San Pablo agreement for exploring quality of life among cancer patient and

informal caregivers,

c) the Clinical Research Office project for the evaluation of diagnostic validity for nutritional risk assessment,

d) the initial steps for the 3M: Ultra: IAD Cavilon Advance High Endurance Skin Protectant: Study which involve

advanced skin care.

During 2015, HIMA•San Pablo Oncologic Hospital incursionated in the second Clinical Trial for FDA Approval. Also the

Hospital obtained a commendation for research activities by the Commission of Cancer after recruting more than 20%

of all cancer patients receiving treatment in the facilities during 2015. Last, local newspaper and other mass

communication media disseminated studies taking place at the institution. A more comprenhensive description of our

achievements is described below.

Clinical Research Víctor Emmanuel Reyes Ortiz, PhD Clinical Research Chief

Hea

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Authors: Wilma González-Barreto1, Francis Javier Galicia-Feliciano1, Aslin Betancourt-Barreto1, Ana Menéndez1, Yashira E. Maldonado-Martínez1, Brenda N. Basabe-Martínez1, Enid M. Beníquez-Cortés1, Beatriz C. Berríos-Ouslán1, Valeria Bobyn-Martínez1, Jean P. Iñesta-Rivera1, Paola Z. Lasanta-Ortiz1, Karla Leavitt-Caraballo1, Ricardo J. Ledesma-Fusté1, Kayssa M. Otero-Aponte1, Cynthia Z. Ruiz-Lorenzo1, Amy C. Silvestrini-Villanueva1, Alexandra Stella-Quiñones1, Ashley Torres-Fonseca1, Marian L. Nuñez-Sierra2, Víctor Emanuel Reyes-Ortiz2

Title: The use of herbal medicine among cancer patients: what, why and how much are they using it?

Abstract: Herbal Medicine has broadly spread worldwide impacting the health of patients elsewhere in different ways.

However, its use and the reasons for seeking complementary medicine is barely documented among Hispanics and less

likely to be documented among Latino Cancer patients. Therefore, this study aims to document the use of herbal medicine

among cancer patients while in radio/chemotherapy. A cross-sectional design was made and 233 patients were randomly

recruited for completing a self-administrated questionnaire. Results were obtained using STATA 13.0, showing that 51%

of all participants use herbal medicine and 40% of them were diagnosed with prostate, breast or colorectal cancer.

Participants reported that herbal medicine increased their self-efficacy thus improved their health status. The herbal

product most frequently used was soursop, ginger and carrots. In terms of quantity of herbal products used they ranged

from 3 – 46 different product (µ=10). Logistic regression showed that those once married or married and those who use

alcohol beverages are 2 – 4 times more likely to use herbal medicine. Multivariate regression showed that among those

who use herbal medicine were those with less annual income, the youngest, with public insurance and with higher

comorbidities will use more herbal medicines. In conclusion, marital status and alcohol use impacts whether or not

patients use herbal medicine. Likewise, out those using it, annual income and medical insurance makes a significant impact

in the quantity on consumption.

Puerto Rico Cancer Research Meeting Universidad Central del Caribe – School of Medicine

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Authors: Mahmoud Aboukhier, HIMA San Pablo, Sergio Fabían-Santiago, Nicole Más-Román, Luis Adrían Ferrer-Gómez, Sara C. Barretos-Arrocho, Rubén O. Brás-Morales, Karla M. Marrero Santos, Indira Nieves, Samille A. Olivera Latorre, Chistina A. Pabón-Carrero, Krizia M. Santos-Rodríguez, Mariela Sosa-Seda, Jessenia Zayas-Rios, Víctor Emanuel Reyes-Ortiz

Title: Burnout among Informal Caregivers of Recently Diagnosed Cancer Patients

Abstract: Burnout is common syndrome suffered by several informal caregivers [IC] of chronic disease patients. However,

literature has been vague defining burnout levels among IC before the subjects face stress related to the disease, thus

unable to describe baseline levels of burnout amongst the population. This descriptive study aims to describe the socio-

demographic characteristics of the patients and their IC, including their quality of life and how it correlates with IC’s

burnout. STATA 13.0 was used for data analysis and p values lower than .10 were reported as significant for a sample size

of 23 informal care-givers recruited at HIMA•San Pablo Oncologic Hospital. Results show that participants’ average age

was 57, mostly women with income of less than 20K. Comorbidities range from 0 – 5 (average = 2) and burnout was

moderate/high for half of the participants. Psychometrics of burnout scale as measured by Cronbach Alpha = .92 and for

quality of life = .86. Correlations among socio-demographic profile of patients or IC did not showed statistical significance,

however reported values for quality of life by IC’s was significantly related to burnout (p = .04). In conclusion, null

hypothesis is accepted as burnout does not statistically correlates to any of the socio-demographic of the patient or IC.

Burnout among the sample seems to be more related to other social and psychological characteristics not measured in

this study. On the other hand, cautious attention should be played to IC as many start with moderate to high burnout

levels which literature had related to patients better prognosis.

HIMA•San Pablo Oncologic Hospital

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Authors: Wilma González-Barreto1, Francis Javier Galicia-Feliciano1, Aslin Betancourt-Barreto1, Ana Menéndez1, Yashira E. Maldonado-Martínez1, Brenda N. Basabe-Martínez1, Enid M. Beníquez-Cortés1, Beatriz C. Berríos-Ouslán1, Valeria Bobyn-Martínez1, Jean P. Iñesta-Rivera1, Paola Z. Lasanta-Ortiz1, Karla Leavitt-Caraballo1, Ricardo J. Ledesma-Fusté1, Kayssa M. Otero-Aponte1, Cynthia Z. Ruiz-Lorenzo1, Amy C. Silvestrini-Villanueva1, Alexandra Stella-Quiñones1, Ashley Torres-Fonseca1, Marian L. Nuñez-Sierra2, Víctor Emanuel Reyes-Ortiz2

Title: The use of herbal medicine among cancer patients: an overview of Latin population.

Abstract: The use of herbal Medicine has broadly spread worldwide and its use has been reported to be independent of

health status or conditions. However, its consumption could be an important risk factor by possible interactions of

ingredients with active agents used in allopathic medicine. It has been reported possible antagonistic, potential and

synergistic effects with the success of cancer treatment. In view of this, this study aims to document the use, quantity and

reason for seeking herbal products as a complement to treatment. A cross-sectional design was made and 233 patients

were randomly recruited while in radiotherapy and/or chemotherapy. Results were obtained using STATA 13.0. As

reported, 81% of participants were diagnosed by first time and 40% of them were diagnosed principally with prostate

cancer, breast cancer or colorectal cancer. 61% of them reported the use herbal medicine as an alternative or complement

to their cancer treatments. 51% of them indicated their physicians were unaware of this consumption. Participants

reported to use from 3-46 products especially soursop, ginger, carrots and Omega 3 (µ=10) to enhance their immune

system and improve their health status. A logistic regression showed that those once married or married and those who

use alcohol were 2 – 4 times more likely in the use of these herbal products. A multivariate regression revealed a higher

use of herbal medicine among those younger, with public health insurance, less annual income and more comorbidities.

In conclusion, the use of these products is influenced by marital status and alcohol consumption. Furthermore, income

and comorbidities predispose participants to consume a higher quantity of these products.

Instituto de Estadísticas de Puerto Rico Expo- Estadísticas 2015

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Authors: Víctor Emanuel Reyes-Ortiz, PhD; Joselyn Pérez-Reyes, RD; Giovanni Carlo Pacheco, BS

Title: Criteria Evaluation of Malnutrition Screening Tool Scale among a Sample of Puerto Rican Hospitalized Patients:

Improving Health Measures in response of Patients’ Best Quality of Care*

Abstract: Malnutrition robust test that allow clinicians to discriminate among “disease/non-disease” patients are difficult

to find thus its administration risk accurate diagnosis. Therefore, we aim to determine the accuracy, sensitivity and

specificity of the MST scale among a randomized sample of patients. Methods: Following the International Test Commission

guidelines the scale was culturally adapted to PR Spanish. Also face and content validity was made to reduce bias in the

administration of the MST and a pilot study was performed assuring the scale minimum psychometrics properties. Using

certified Nutritionist as gold standard for comparison MST was administrated to 113 hospitalized patients. STATA 12.0 was

used for ROC, AUC and factorial analysis of the MST scale. Results showed that cutoff point among the population differs

(3 pts) from the original cutoff point (2 pts); also sensitivity and specificity demonstrated to vary showing lower sensitivity

and specificity (88% vs 93% and 59% vs 93% respectively). AUC after change of cutoff point was .73 also differing from

original validation. Last Eigenvalue of the scale given by confirmatory factorial analysis equals 1.74 with all factorial loads

over .60. Besides the lower sensitivity and specificity of the MST Scale in the Puerto Rican population, evaluation of

psychometric properties of the scale helped to improve the accuracy of malnutrition diagnosis and to optimize the

discrimination between “disease/non-disease” patients.

* Recognized as best poster presentation for statistical design in the development public policy and translational research.

Jamaica Statistic Symposium 2015* Kingston, Jamaica

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PATIENT OUTCOMES

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Prevention and Screening Programs Maricarmen Ramírez-Solá, MPHE Public Health Educator & Community Outreach Coordinator

Objectives …

To create awareness and reduce incidence of specific types of cancer.

To increase cancer

detection in early stages and reduce cancer-related mortality in Puerto Rico.

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BREAST CANCER PREVENTION PROGRAM

Areas of community needs

Health Education activity performed

Guidelines followed

Follow-up system

Lack of information about breast cancer early detection according to a 2014 community survey. Breast cancer most commonly diagnosed and leading cause of death in women (Puerto Rico Cancer Central Registry, 2010).

Group interventions: 2 Total participants: 45 Target population: men and women of different ages Location: Hospital X-Rays Unit waiting room Dates: April 8 & 22, 2015

American Cancer Society (ACS) Centers for Disease Control & Prevention (CDC) Susan G. Komen (SGK)

Telephone calls (n=23)

Results: 22% learned mammogram is recommended yearly at 40≥. 17% of female participants made appointment for a mammogram (n=18). 52% talked to relatives and friends about breast cancer early detection and/or symptoms.

Corrective action: To focus future health education interventions in concrete behavioral actions related to breast cancer early detection instead of focusing in the clinical aspects of disease.

http://www.google.com.pr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=http://www.diyagas.com/Staff/images/&bvm=bv.122676328,bs.2,d.dmo&psig=AFQjCNGufzLj0imdEq8Q_EczWTemJanTqw&ust=1464050058607640

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BREAST CANCER SCREENING PROGRAM

Areas of community needs

Activity performed

Guidelines followed

Follow-up system

Removal of barriers such as co-pays and working time lost for breast cancer early screening. Breast cancer most commonly diagnosed and leading cause of death in women (Puerto Rico Cancer Central Registry, 2010).

Activation of institutional mammogram program for regular employees with no co-pay Target population: 102 women Location: Hospital facility Period: April, 2015

Centers for Disease Control & Prevention (CDC)

Participants with positive findings were referred to Breast Cancer Navigator.

Results: 8% (8) positive findings. 64% increase in participation compared with same period in 2014.

Corrective action: To extend benefit for regular employees from 3 to 12 months.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=http://liveandlovecrafts.blogspot.com/2012/10/think-pink-candy.html&bvm=bv.122448493,d.aXo&psig=AFQjCNHLxOvNlxPJ1gDfItgvN7kolenl6g&ust=1464051858252306

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PROSTATE CANCER SCREENING PROGRAM

Areas of community needs

Activity performed

Guidelines followed

Follow-up system

Prostate cancer most commonly diagnosed and leading cause of death in men (Puerto Rico Cancer Central Registry, 2010).

Free of charge PSA clinics with education on pros & cons of PSA test Target population: 183 males 40≥ years old Location: 5 municipalities in the Northeastern region of Puerto Rico (Luquillo, Fajardo, Ceiba, Naguabo, Caguas) Period: 14 clinics from January to August, 2015

American Cancer Society (ACS) American College of Physicians (ACP)

Telephone calls & referrals for medical follow-up.

Results:

6% (12) participants with PSA abnormal values. 50% participants with PSA abnormal values answered follow-up calls (n=6):

o 1 in watchful waiting o 1 negative biopsy

http://www.google.com.pr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=http://www.diyagas.com/Staff/images/&bvm=bv.122676328,bs.2,d.dmo&psig=AFQjCNGufzLj0imdEq8Q_EczWTemJanTqw&ust=1464050058607640

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o 1 negative biopsy but referred for smoking cessation o 2 referred by primary physician to urologist o 1 forgot to get result, encouraged to do so.

Corrective actions: Review of PSA clinics protocol -- adding a mechanism to contact participants with abnormal PSA results by mail if not reached by phone; updating list of urologists for referrals; supporting health education regarding pros & cons of PSA test with written information.

2015 Education, Prevention and Screening Events

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Prostate

COMMUNITY OUTREACH Photo Gallery

Health Education at HIMA•San Pablo Oncology Foundation Fund Raising Event, June 2015

4th Voices of Hope Christmas Concert. Puppets and the Puerto Rico National Circus for non-traditional emotional support to pediatric cancer patients and relatives, December 2015

Health Education about strategies to reduce stress and therapeutic massage for patients in the Radiation Therapy Unit, June 2015.

Breast Cancer Awareness Event with Stiletto Conquest, October 2015.

Cancer Screening Program, August 2015

2015

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Objective …

To develop and implement an educational guide to improve pediatric patient comprehensive care when diagnosed.

“Anecdotic data from support group meetings provided input for the development of an educational guide for pediatric cancer patients and their relatives.” Maricarmen Ramírez-Solá, MPHE

Educational Support

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EDUCATIONAL GUIDE FOR PEDIATRIC CANCER PATIENTS

Activities performed Readers Evaluation* (Ordinal Scale 0-4)

1. Data recollection in support group meetings (2012-13)

2. Development of a list of topics / content outline 3. Qualitative analysis of content outline and

literature review 4. Creation of an Editorial Committee 5. Writing 6. Printing of first draft (April, 2014) 7. Evaluation of reader panel* and content review.

and editing (June & July, 2014) 8. Discussion and review of second draft

(August 2014) 10. Graphic design (December 2014) 11. Publication (September 2015) 12. Use of educational guide for patient/relatives Health Education. Reader Panel: Pediatric patient caretakers (3), Officials from the American Cancer Society Puerto

Rico Chapter (2), Retired Professor from the University of Puerto Rico School of Education (1) & Llay person (1).

Help patients and relatives to deal with DX 4.0 Has an adequate, easy to read vocabulary 4.0 Includes relevant topics 4.0 Has an appropriate amount of content 4.0 Will be read as reference 3.7 TOTAL PUNCTUATION: 3.9

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Link for digital version - http://himasanpablo.com/guia-para-oncologia-pediatrica

Hard copy educational guide presentation, September 2015

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Family Meetings

The HIMA•San Pablo Oncologic Hospital follows a patient-centered approach throughout a

multidisciplinary team of health professionals specially trained to provide holistic medical and

psychosocial care. This approach is highly valuable in Pediatric Oncology Wards in which the families

deal with high level of distress after a pediatric cancer diagnosis.

Multidisciplinary interventions not only support patients, but also parents, siblings and other family

members and caretakers as well. While experiencing very strong emotions, parents or legal tutors

are responsible to make decisions in order to proceed with cancer treatment in a timely manner.

When applicable, patients are also encouraged to participate in the decision making process with the

support and guidance of the multidisciplinary team. Extended family in the Puerto Rican culture is

extremely important and relevant in childbearing. That is why the opinion of relatives such as

grandparents and uncles, in some instances also has to be considered in healthcare decision making.

Multidisciplinary Support

Maribel Delgado-Colón, MSW Psychosocial and Palliative Care Coordinator

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To facilitate patient/family adaptation to a cancer diagnosis, and to improve patient/family

communication with the medical staff, the Pediatric Oncologists may assemble Family Meetings.

These meetings are useful to keep patients and family members informed and to achieve a better

understanding of the diagnosis and medical treatment. When the patient moves to a new stage in

the cancer continuum, meetings may be crucial to determine the next step to be followed granting

consideration to patient/family ideas and concerns. New biopsy results, cancer recurrences,

metastasis, or treatment failure and the need to consider palliative and comfort support instead of

curative care, are examples of new developments in the cancer continuum that justify a supportive

environment to set new goals for the medical care.

The Pediatric Oncologists lead Family Meetings at HIMA•San Pablo Oncologic Hospital. Attendance

to meetings includes patient and relatives, the Oncology Nurse, Social Worker, Health Educator,

Psychologist and Chaplain, when applicable. Each allied health professional intervenes according to

its qualifications providing support to the oncologists and to patients and their relatives. Frequently,

assisting in decision making and improving patient/family support and quality of life are the primary

goals of the Family Meetings.

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The Chemo Duck Searching for the best resources available to support pediatric patient adaptation to the hospital setting, a donation

of the Chemo Duck was requested to the HIMA•San Pablo Oncologic Foundation; a non-profit organization

providing economic and psychosocial support to cancer patients in Puerto Rico. The Chemo Duck is a cuddly toy

designed by Gabe’s Chemo Duck, an educational program from Gabe’s Heart non-profit organization supporting

children and families living with cancer.

The Chemo Duck was created for patients over 3 years of age. It comes with a Med Port, a Pick Line, a head

bandana, a coloring book and a carrying bag. The Chemo Duck encourages communication between patients and

the medical/psycho-educational staff. It is used in play therapy by the Clinical Psychologist to help pediatric

patients talk about “scary feelings” to then integrate the experience in order to build resilience.

Psychological Support

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The Clinical Psychologist and the Health Educator also utilize the Chemo Duck to achieve the following objectives:

To develop good rapport and a trustful interaction with patients and relatives.

To help pediatric patients express their ideas and feelings in a healthy way to better process strong emotions.

To assess protective and risk factors influencing patients adjustment to invasive medical interventions.

To help pediatric patients rehearse medical experiences and self-care practices.

To promote understanding of medical procedures.

In 2015, pediatric patients at HIMA•San Pablo Oncologic Hospital began to receive a Chemo Duck as a companion pal to be brought to all medical appointments and hospitalizations.

Amalia Alicea Rivera, PsyD Clinical Psychologist

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Protocol for the Early Detection, Evaluation, Diagnosis and Treatment for Malnutrition of the Oncology Patient

Malnutrition, from the point of view of cancer, could be defined as the set of deficit in the composition of various

bodily aspects induced by tumor disease. This situation interferes with the normal neoplasia response, as well as the

effectiveness of cancer therapy. This may cause a decrease in the survival probability of cancer patients. Malnutrition

is one of the most significant problems during cancer treatment. It is characterized by complicated symptoms

including weight loss, poor scarring, muscle mass loss, chemical and electrolytic imbalance, increased morbidity,

immune system depression and mortality. Malnutrition decreases quality of life, reducing muscle strength, and

increasing weakness, fatigue and depressive symptoms.

The maximum expression of malnutrition is cancer-induced cachexia (CACS, for its acronym in English) which is

responsible for the directly or indirectly death of cancer patients. Cancer-induced cachexia is a multifactorial

syndrome accompanied by a spectrum of changes ranging from weight loss to a significant deterioration in the lean

muscle tissue and body fat. All these changes increase the morbidity and mortality of cancer patients. The patient

who presents cancer-induced cachexia or malnutrition during cancer treatment reflects further alterations in physical

image that adversely affects self-esteem, interpersonal relationships, physical activity and social functions. Each

stage of treatment is associated with different needs and challenges both for the patient, caregivers and clinical staff

that is at the service of the patient.

Nutritional Support Joselyn Pérez-Reyes, RD Oncology Registered Dietitian

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Early detection, evaluation, diagnosis and treatment for malnutrition of the oncology patient are necessary to

prevent major nutritional risks. That justified the development of a protocol at HIMA•San Pablo Oncologic Hospital

to identify patients at early stages of treatment who are on a very high risk of malnutrition. Therefore, during

patient early assessment, the Medical Oncologist, Radio Oncologist and/or Oncology Nurse complete a referral for

the Oncology Dietitian (OD). The OD then completes a nutritional evaluation to initiate medical-nutritional therapy

to prevent malnutrition and/or manage developed symptoms associated with treatment. Adequate nutritional

support has proved to help patients complete their cancer treatment and, therefore, experience less toxicities.

It is important to highlight that each treatment modality; chemotherapy, radiotherapy, immunotherapy, and/or surgery, promotes deterioration in patient nutritional status. Nutritional support is essential as cancer treatment unsettle absorption of nutrients in the gastrointestinal system with the potential to induce secondary malnutrition from treatment.

ONCOLOGY TREATMENT MODALITIES AND MALNUTRITION

TREATMENT NUTRITIONAL IMPACT Surgery Early satiety, malabsorption, dehydration, abdominal cramps, nausea, vomit, diarrhea, flatulence constipation,

fluid and electrolytic imbalances, lactose intolerance, food intolerance, hyperglycemia, etc.

Chemotherapy cytotoxicity

Nausea, vomit, anorexia, diarrhea, constipation, neutropenia, fatigue, mucositis, peripheral neuropathy, dyspepsia, changes on taste, metallic taste, enteritis, colitis.

Hormonal Hyperglycemia, edema, osteoporosis, nausea, vomit, hypercalcemia.

Immunotherapy Hyperglycemia, nausea, vomit, diarrhea, fatigue, neutropenia.

Radiotherapy Head, Neck & Oropharyngeal Area: anorexia, changes in smell and taste, xerostomia, mucositis, odynophagia, dysphagia, fatigue. Thorax Area: Anorexia, dysphagia, esophagitis, reflux, early satiety, fatigue. Abdomen & Pelvic Area: nausea, vomit, diarrhea, abdominal cramps, flatulence, gastrointestinal upset, lactose intolerance, malabsorption, colitis, enteritis.

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CONTINUUM OF CARE

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Objectives …

To promote healthy lifestyles and proper management of comorbidities and psychosocial side effects of treatment.

To monitor cancer recurrences, metastasis or new primaries.

To improve survivor quality of life.

Survivorship Care Plan

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SURVIVORSHIP CARE PLAN (SCP) - Institutional Level

Activities performed

Guidelines followed

Created a SCP Ad hoc Sub-Committee Updated 2013 SCP Policy & Procedures Reviewed & developed SCP templates Pilot implementation: breast & prostate cancer patients completing first course TX, Stage I or II of disease, no metastasis nor recurrence Identified 2014 baseline total analytic cases to calculate 2015 compliance level in the delivery of SCP

American Society of Clinical Oncology (ASCO) Commission on Cancer of the American College of Surgeons (CoC) National Comprehensive Cancer Network (NCCN) Centers for Disease Control & Prevention (CDC)

2015 CoC Requirement: Delivery SCP to 10 % eligible patients.

Achieved: Delivery to 11% eligible patients.

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SURVIVORSHIP CARE PLAN (SCP) - National Level

Activity performed

Awareness Message

Joined the Puerto Rico Cancer Control Coalition (PR-CCC). Participated in the development of the Puerto Rico Cancer Control Action Plan 2015-2020. Continued to lead the PR-CCC Survivorship and Quality of Life Working Committee. Helped to develop and implement a National Cancer Survivorship Digital and Mass Awareness Campaign through TV, radio, scientific forum presentations, press and e-mail (June, 2015).

2015 PR-CCC Survivorship Objective: Increase 10 % the number of cancer survivors who receive a survivorship care plan as quality standard of care in oncology.

Achieved: Increase 94% visits to the PR-CCC fan page, possibly an indirect measure of awareness.

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QUALITY IMPROVEMENT

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Carmen Meléndez Lavandero, RRT Radiation Therapy Supervisor

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STUDY OF QUALITY

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Objective …

To perform an evaluation of pilot implementation of end of life protocol.

“Caring for patients near the end of life is extremely important. This protocol will help the health care team to provide the best supportive care possible to patients with advanced disease, and their caretakers.” Maribel Delgado-Colón. MSW

End of Life Protocol

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END OF LIFE PROTOCOL - Quantitative Evaluation

Period Methodology Results Corrective Actions

March - June 2015

Data abstraction from patient medical record with check-list evaluation form

- Protocol activated 6 times in

evaluation period with adult patients having life expectancy of ≤6 months.

- Expected time of 48 hours for interventions was met.

- 70% of palliative care team members intervened: physician, nurse, nutritionist, social worker, psychologist, health educator and pharmacist.

- 20% oncologists activated protocol in pilot implementation (N=10).

- 50% of oncology nurses

surveyed were certain of existence of protocol ((n=6).

- Meetings with oncologists to be

performed to point out benefits of multidisciplinary end of life care.

- Members of the health care team

to be authorized to activate the protocol with oncologist’s approval.

- Information dissemination

regarding end of life protocol to be included during oncology nurse staff meetings.

- Formal interventions by spiritual

counselor to be formalized and added to the protocol.

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END OF LIFE PROTOCOL - Qualitative Evaluation

Period Methodology Results / Corrective Actions March - June

2015

Multidisciplinary meetings with documentation of process performance

- Input meeting to be added as first step of protocol activation.

- Psychosocial Coordinator and Clinical Psychologist to be identified as

team members to first intervene, as far as their assessment lead subsequent multidisciplinary interventions.

- Risk Management Official to be called for consultation in the absence

of patient Do Not Resuscitate (DNR) notice.

- Chaplain to be added to the palliative care team.

- Follow-up communication with patient relatives to be added as closure when a patient dies.

- Algorithm / visual flow chart for the delivery of interventions to be

developed.

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DATA QUALITY

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Certified Tumor Registrars

Besaida Ruíz Conde BPH,RT, CTR Amarilys López Rodríguez BS, CTR Arelis M. Hernández Rosado MPH, CTR

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The Cancer Registry at HIMA•San Pablo Oncologic Hospital gathers information on all tumors diagnosed or treated at the Institution. During 2015, 1,175 analytic cases and 171 non-analytic cases were added to our registry database. This data is transmitted to the National Cancer Data Base (NCDB) and to the Central Cancer Registry. The NCDB is maintained by the Commission on Cancer. We give active follow-up to more than 4,000 patients annually, maintaining a 97% follow-up rate.

In the geographical distribution at diagnosis for 2015, the main county is Caguas with 378 (28.06%) patients

diagnosed or treated in the Institution. Significant percent of patients are from neighboring counties as Gurabo

(7.20%), San Lorenzo (6.53%), Juncos (5.35%) and Humacao (5.20%). Otherwise, remaining counties contribute

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among 3.93% to 0.07% each. Also, 21 patients from U.S. Virgin Islands were diagnosed or treated on our

Institution.

The Cancer Registry at HIMA•San Pablo Oncologic Hospital is a detailed database of each tumor type diagnosed or

treated at the Institution and it’s a vital component of the Cancer Program. Continuous monitoring of the survivors

and recurrence statistics of the conditions raises the standards of treatment and care for the cancer patients, and

it also gathers data to launch new research and clinical trials.

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Of the total 1,346 cases added to our database in 2015, 760 cases (56.5 percent) were females, and 586 cases (43.5

percent) were males. The female top 10 sites added to our database in order of decreasing frequency were: breast

(238), thyroid gland (96), uterus (65), colon (49), brain (33), cervix (32), bronchus and lung (31), lymph nodes (27),

meninges (24), and ovary (22). There were 143 female cases that represent all other primary sites. The male top 10

sites in order of decreasing frequency were prostate (203), lung/bronchus (43), hematopoietic (34), colon (33),

thyroid gland (25), brain (23), lymph nodes (22), kidney (19), liver and intrahepatic ducts (15) and stomach (15).

154 male cases represent all other primary sites. Together, these cases made the top 5 sites of HIMA San Pablo

Oncological Hospital in order of decreasing frequency as follow: breast (239, 17.8 percent), prostate (203, 15.1

percent), thyroid gland (121, 9 percent), colon (82, 6.1 percent), bronchus (74, 5.5 percent). All other primary sites

in addition of this top 5 represent 46.5 percent.

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M F A* NA** Alive Exp 0 II III IV586 760 1,175 171 1,275 71 46 160 112 11032 12 41 3 42 2 0 1 10 16103 101 177 27 175 29 5 31 43 28

4 1 5 0 4 1 0 1 1 1

12 9 17 4 15 6 0 3 6 2

3 1 4 0 4 0 0 2 2 0

33 48 69 12 73 8 3 19 22 11

16 12 22 6 27 1 1 1 7 2

0 6 6 0 5 1 0 1 1 2

15 4 15 4 16 3 0 0 0 2

0 3 3 0 3 0 1 0 1 0

1 0 1 0 1 0 0 0 0 0

10 7 16 1 13 4 0 4 3 7

1 1 2 0 2 0 0 0 0 1

0 2 2 0 2 0 0 0 0 0

8 7 15 0 10 5 0 0 0 0

59 31 78 12 79 11 0 5 10 26

2 2 2 2 2 2 0 0 1 1

15 0 13 2 15 0 0 2 2 1

42 29 63 8 62 9 0 3 7 24

4 1 5 0 5 0 0 0 0 1

0 3 3 0 3 0 0 0 0 0

7 2 6 3 7 2 0 1 0 1

6 1 4 3 5 2 0 1 0 1

1 1 2 0 2 0 0 0 0 0

1 238 212 27 239 0 35 32 12 3

0 127 118 9 122 5 1 11 26 12

0 32 31 1 31 1 0 5 9 4

0 65 62 3 64 1 1 2 12 2

0 22 19 3 20 2 0 4 4 6

0 2 1 1 2 0 0 0 0 0

0 4 4 0 4 0 0 0 1 0

0 2 1 1 1 1 0 0 0 0

211 0 187 24 208 3 0 77 1 6

203 0 182 21 200 3 0 76 1 6

6 0 3 3 6 0 0 0 0 0

2 0 2 0 2 0 0 1 0 0

33 13 39 7 43 3 5 1 3 3

14 3 15 2 14 3 5 1 1 1

19 9 23 5 28 0 0 0 2 2

0 1 1 0 1 0 0 0 0 0

31 59 79 11 87 3 0 0 0 0

32 110 138 4 141 1 0 0 4 3

25 96 121 0 121 0 0 0 4 3

7 14 17 4 20 1 0 0 0 0

35 34 51 18 64 5 0 1 3 11

10 5 8 7 13 2 0 0 1 0

25 29 43 11 51 3 0 1 2 11

22 12 14 20 32 2 0 0 0 0

10 4 10 4 12 2 0 0 0 0

0 1 0 1 0 1 0 0 0 0

6 12 17 1 16 2 0 0 0 0

Data based on HIMA San Pablo Oncologic Hospital 1st contact year 2014.

* Analytic (A): diagnosed and/or received first course treatment at HIMA San Pablo Oncologic Hospital.

*** Status: data obtained from patients alive or expired from follow-up done until 11/17/15.

DIGESTIVE SYSTEM (204) 20

ORAL CAVITY & PHARYNX (44) 3

SexClass of

Case

Small Intestine (4) 0

Stomach (21) 3

Esophagus (5) 0

Anus (6) 0

Rectum & Rectosigmoid (28) 4

Colon (81) 11

Other Biliary (1) 0

Gallbladder (3) 0

Liver & Intrahepatic Bile Duct (19) 1

Peritoneum, Omentum & Mesentery (2) 0

Retroperitoneum (2) 0

Pancreas (17) 1

Nose, Nasal Cavity (4) 0

RESPIRATORY SYSTEM 5

Other Digestive (15) 0

BONES & JOINTS (5) 0

Lung & Bronchus (71) 1

Larynx (15) 4

Melanoma (7) 0

SKIN (9) 0

SOFT TISSUE (3) 0

FEMALE GENITAL SYSTEM (127) 37

BREAST (239) 65

Other Non-Epithelial (2) 0

Ovary (22) 1

Corpus & Uterus (65) 26

Cervix Uteri (32) 8

Other (2) 0

Vulva (4) 2

Vagina (2) 0

Testis (6) 0

Prostate (203) 66

MALE GENITAL SYSTEM (211) 66

3

Urinary Bladder (17) 0

URINARY SYSTEM (46) 3

Penis (2) 0

Thyroid (121) 45

ENDOCRINE SYSTEM (142) 45

Status***

BRAIN & CNS (90) 0

Ureter (1) 0

Kidney & Renal Pelvis 928)

Hodgkin Lymphoma (15) 5

LYMPHOMA (69) 20

Other Endocrine (21) 0

LEUKEMIA (14) 0

MYELOMA (34) 0

Non-Hodgkin Lymphoma (54) 15

PRIMARY SITE

** Non-Analytic (NA): All cases for which the registry does not have information on the original diagnosis and/or first course of

treatment. (E.g. treatment was for persistent disease; metastatic disease; recurrence, palliative).

Total (1,346) 264

AJCC STAGE AT DIAGNOSIS

(ONLY ANALYTIC CASES)

I

OTHER (18) 0

MESOTHELIOMA (1) 0

2015 CANCER SITE REPORT

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How RQRS help

improving patient care?

Estrogen (ER) and progesterone

(PR) are hormones produced by

the ovaries. ER-PR may promote

the growth of some breast

cancers so a patient which is ER-

PR positive, may be benefited by

hormone therapy as it reduces

her risk for recurrences.

In a real case RQRS identified a

breast cancer patient who

finished treatment but for some

reason did not started hormone

therapy in the time frame

required. HIMA•San Pablo

Oncologic Hospital Cancer

Registry Official shared the

information with Patient

Navigator who at the same time

sent an alert message to the

Oncologist to make sure patient

was not sorted out of best

standard of clinical care.

RQRS Rapid Quality Report System

Besaida Ruiz Conde RT, CTR, BPH Certified Tumor Registrar

HIMA•SAN PABLO ONCOLOGIC HOSPITAL HAS BEEN PARTICIPATING IN THE RQRS SINCE 2014 AS A COC ACCREDITED INSTITUTION. THE SYSTEM PROMOTE AND FACILITATE EVIDENCED-BASED, HIGH QUALITY CARE IN ACCORDANCE WITH BEST STANDARDS OF CARE IN ONCOLOGY

MEDICINE.

HOW THIS HELP OUR PATIENT?

RQRS HELPS TO MONITOR PATIENT

CONTINUUM OF TREATMENT IN CLINICAL

REAL TIME, REDUCING TREATMENT DELAYS

AND IMPROVING TREATMENT COMPLIANCE

AND PATIENT OUTCOMES.

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HIMA•San Pablo Oncologic Hospital

Cancer Alliances

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Am

eri

can

Can

cer

Soci

ety

P

uert

o R

ico C

ha

pte

r

20

15

‘Look Good Feel Better’ Program

Collaborative Events

Total Participants

I Can Cope Program -Yo Puedo

457

Look Good Feel Better Program

31

4th Voices of Hope Christmas Concert 100

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HIM

A•S

an P

ablo

On

colo

gic

Fou

nd

atio

n

HIMA•San Pablo Oncologic Foundation Supporting the American Cancer Society Relay for Life 2015

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Susa

n G

. Ko

me

n P

R

HIMA•San Pablo Oncologic Foundation supporting Susan G. Komen Race for the Cure 2015

The HIMA•San Pablo Oncologic Foundation was granted a program to provide economic

support to breast cancer patients

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Cancer Committee &

Medical Faculty

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Chairman Edgardo J. Rodríguez Monge, MD Medical Director, HIMA•San Pablo Oncologic Hospital

Administration Mayra M. Collazo Castro, MD, CTR Director, HIMA•San Pablo Oncologic Hospital

Cancer Liaison Physician Ramón K. Sotomayor, MD, FACS Chief, Surgical Oncology

Cancer Registry Quality Coordinator Julio A. Arce Cortes, BAS, CTR Cancer Tumor Registrar

Community Outreach Coordinator Maricarmen Ramírez-Solá, MPHE Public Health Educator

Psychosocial Services Coordinator Maribel Delgado Colón, MSW Social Worker

Quality Improvement Coordinator Irma Cruz Delgado, RN, BSN, OCN Oncology Nurse Supervisor

Clinical Research Chief Victor Reyes Ortiz, PhD

Cancer Conference Coordinator Priscilla González González

Patient Navigator Jaluxmi Villegas Meléndez, RN, BSN

Breast Cancer Patient Navigator Karmín Rodríguez Ríos, MSW

Carlos Gonzalez García, MD, DABR Diagnostic Radiology

José R. Santana Rabell, MD Radiation Oncology

Luis E. Ferrer Torres, MD, FACP Director, Anatomic & Clinical Pathology

Jhon A. Guerra Moreno, MD, FAAP Director, Pediatric Hematology & Oncology Bone Marrow Transplant

Additional Members

Joselyn Pérez Reyes, RD Nutritionist – Dietitian

Maria Cristy American Cancer Society Staff Representative

Orlando Rodríguez Pastoral Care

Irma Y. Estrada, PharmD Manager, Clinical Pharmacy

Norma Salgado Vila, MD Director, Bone Marrow Transplant Unit

Jesús M. Vidal Palau, MD Director, Nuclear Medicine

Lisbeth Wys-Mirabal, PsyD Psychosocial Aspects of Cancer Care

HIMA•San Pablo Oncologic Hospital Cancer Committee

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ONCOLOGY Carlos E. Méndez Serrano, MD American Board of Internal Medicine American Board of Medical Oncology American Board of Hematology (787) 744-8686 Caroline Rivera Olmos, MD American Board of Internal Medicine American Board of Medical Oncology American Board of Hematology (787) 744-8686 Edgardo J. Rodríguez Monge, MD Medical Director, HIMA•San Pablo Oncologic Hospital (787) 744-8686 Evelyn M. Fonseca Rivera, MD Hematology & Oncology (787) 744-8686 José A. Fernández Chávez, MD American Board of Internal Medicine American Board of Medical Oncology American Board of Hematology (939) 337-8107 Juan Cintrón López, MD Hematology & Oncology (787) 743-3437

María V. García Pallas, MD American Board of Internal Medicine American Board of Medical Oncology American Board of Hematology (939) 337-8107 Maribel Cotto Santiago, MD American Board of Internal Medicine American Board of Medical Oncology American Board of Hematology (787) 744-8686 Norma R. Salgado Vilá, MD Director, Bone Marrow Transplant Unit American Board of Internal Medicine American Board of Hematology (787) 653-1300 Ext. 7706, 7719 Omayra L. González Rodríguez, MD American Board of Internal Medicine American Board of Hematology (787) 961-4888 Yazmín Corujo Sánchez, MD Hematology & Oncology (787) 744-8686

HIMA•San Pablo Oncologic Hospital Medical Faculty

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PEDIATRIC ONCOLOGY Jhon A. Guerra Moreno, MD, FAAP Director, Pediatric Hematology & Oncology Bone Marrow Transplant American Board of Pediatrics American Board of Hematology & Oncology (787) 653-3434 Ext. 7725 Maribel Torres Serrant, MD American Board of Hematology and Oncology Pediatric Hematology & Oncology (787) 653-3434 Ext. 7725 RADIOLOGY Carlos Gonzalez García, MD, DABR American Board of Radiology (787) 653-3434 Ext. 1440 Cesar F. Cortes Cardona, MD American Board of Radiology American Board of Pediatric Radiology Daniel Mendez Cruz, MD American Board of Radiology (787) 653-3434 Ext. 1440 Eduardo Labat Alvarez, MD American Board of Radiology American Board of Neuroradiology (787) 653-3434 Ext. 1440

Edward Macburney Henriquez, MD American Board of Radiology (787) 653-3434 Ext. 1440 José L. Valderrábanos Marina, MD Director, Radiology Service American Board of Radiology (787) 653-3434 Ext. 1440 Josué Vázquez Delgado, MD American Board of Radiology (787) 653-3434 Ext. 1440 María A. Muns García, MD American Board of Radiology (787) 653-3434 Ext. 1440 Mario E. Torres León, MD American Board of Radiology (787) 653-3434 Ext. 1440 Pedro González Torres, MD American Board of Radiology (787) 653-3434 Ext. 1440 Rafael A. Vicéns Rodríguez, MD American Board of Radiology (787) 653-3434 Ext. 1440

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RADIATION ONCOLOGY Carlos M. Chévere Mouriño, MD Medical Director, Radiation Oncology (787) 653-1300 Ext. 7721 José R. Santana Rabell, MD, CTR American Board of Radiology (787) 653-1300 Ext. 7721 Julio J. Díaz Padilla, MD Radiation Oncology (787) 653-1300 Ext. 7706 NUCLEAR MEDICINE Jesús M. Vidal Palau, MD Director, Nuclear Medicine (787) 653-3434 Ext. 1310 César Boris Solá, MD American Board of Nuclear Medicine (787)653-1310 NEURO-ONCOLOGY David E. Blás Boria, MD Neuro-oncologist American Board of Neurology (787) 653-1300

INTERVENTIONAL RADIOLOGY Javier Nazario Larrieu, MD American Board of Radiology American Board of Vascular and Interventional Radiology (787) 653-3434; (787) 620-4747 Ext. 4316 Mario J. Polo Asenjo, MD Neuroradiology & Neurointerventional Surgery American Board of Radiology American Board of Neuroradiology (787) 653-3438 Ext. 5101 Martín Gorrochategui Vigoreaux, MD American Board of Radiology American Board of Vascular and Interventional Radiology (787)653-1771 Ricardo Cruzado Ceballos, MD American Board of Radiology American Board of Vascular and Interventional Radiology (787)653-1771 PATHOLOGY Dana I. Delgado Colón, MD, FACP American Board of Anatomical & Clinical Pathology American Board of Hematological Pathology (787) 653-0066

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Isabel Matos Llovet, MD, FACP American Board of Anatomical Pathology (787) 653-0066 Jorge G. Billoch Lima, MD, FACP American Board of Anatomical & Clinical Pathology (787) 653-0066 Juan L. Pérez Berenguer, MD, FACP Neuropathology American Board of Anatomical Pathology American Board of Neuropathology (787) 653-0066 Katia E. Rosado Orozco, MD, FACP American Board of Anatomical & Clinical Pathology (787) 653-0066 Guillermo Villamarzo, MD, FACP Medical Director, Pathology American Board of Anatomical Pathology (787) 653-0066 Luis E. Ferrer Torres, MD, FACP Technical Director, Anatomic & Clinical Pathology American Board of Anatomical & Clinical Pathology (787) 653-0066 Luis M. Lozada Muñoz, MD, FACP American Board of Anatomical & Clinical Pathology (787) 653-0066

Mariclara Torrellas Ruiz, MD Anatomical & Clinical Pathology (787) 653-0066 Miosoti Garcia Maldonado, MD, FACP American Board of Anatomical Pathology (787) 653-0066 Roberto Betances Carreras, MD, FACP American Board of Anatomical Pathology (787) 653-0066 Vicmari Arce Rodríguez, MD, FACP American Board of Anatomical & Clinical Pathology (787) 653-0066 GYNECOLOGY Jesús M. Salgueiro Bravo, MD Obstetrics and Gynecology American Board of Obstetrics & Gynecology (787) 653-3456 Pedro F. Escobar Rodríguez, MD Gynecologic Oncology, Breast Surgery, Laparoscopy and Robotic Surgery American Board of Obstetrics & Gynecology American Board of Gynecologic Oncology (787) 653-3456

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SURGERY Andrés Guerrero Rodríguez, MD, FACS Chief, Surgery Department American Board of Surgery American Board of Surgical Critical Care (787) 961-4211 Bolívar Arboleda Osorio, MD, FACS Breast Surgery American Board of Surgery (787) 961-4211 Carlos E. Pérez Mitchell, MD Head & Neck Surgery and TORS American Board of Otolaryngology (787) 653-1300 Diana Avilés Castillo, MD Plastic & Reconstructive Surgery American Board of Plastic Surgery (787) 653-3439 Felix Figueroa Pérez, MD General Surgery (787)258-2965 Iván J. Sósa González, MD Board of American Neurological Surgery (787)765-8276

Jorge Cordero Soto, MD General Surgery (787)653-0550 Arelio Segundo Díaz, MD American Board of Surgery (787)727-4953 José R. Alvarez Ruiz, MD Pediatric Gastroenterologist American Board of Surgery (787) 655-0505 Juan C. López de Victoria, MD American Board of Surgery (787) 653-3126 Julio A. Ortiz McWilliams, MD American Board of Surgery (787)850-4255 Luis A. Aponte López, MD Vascular Surgery and General Surgery American Board of Surgery (787) 745-2790 Luis J. Almodóvar Fábregas, MD Oncologic Neurosurgery Board of American Neurological Surgery (787) 653-1300

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Manuel R. Gracia Ramis, MD American Board of Surgery (787) 653-3126 Maria Toledo Gonzalez, MD Board of American Neurological Surgery (787) 653-6060 Michelangelo Santiago Sánchez, MD American Board of Surgery (787) 653-3126 Ramón K. Sotomayor, MD, FACS Chief, Surgical Oncology American Board of Surgery (787) 961-4211 Víctor B. Malave Rolón, MD General Surgery American Board of Surgery (787) 600-4404 UROLOGY Alvin López Pujals, MD American Board of Urology (787) 744-0509 Antonio Yulian Valentín, MD American Board of Urology (787) 744-0670

Freddy R. Méndez Torres, MD American Board of Urology (787) 738-1380 Jorge L. Rivera Jiménez, MD American Board of Urology (787) 744-3135 Leonel E. Guerrero Rodríguez, MD American Board of Urology (787) 863-1212 Marcial A. Walker Ballester, MD American Board of Urology (787) 704-4141 Ramón G. Ramos Cartagena, MD American Board of Urology (787) 744-0509 Timoteo Torres Santiago, MD American Board of Urology (787) 743-8682 Víctor M. Rivera Jiménez, MD American Board of Urology (787) 744-3135 Wilfredo López Hernández, MD Urology (787) 746-4500

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Nadie te cuida como nosotros.